늘 푸른이처럼

운동이나 작업등으로 팔을 과도하게 사용함으로서 발생하는 팔꿈치의 통증 및 팔운동 제한을 일으키는 대표적인 질환으로서 팔꿈치 안쪽이나 바깥쪽의 상과염을 말한다.

30~50세 사이에 대부분 잘 발생하지만 어느 나이라도 생길수 있다.
팔을 반복 사용해야만 하기 때문에 재발하기 쉽고 잘 낫지 않아 나중에는 컵하나도 들지 못할 정도로 일상 생활에 지장을 일으키는 경우도 있다.
일시적인 증상 완화방법으로 좋아지는듯 하지만 시간이 지날수록 점차 증상이 악화되어서 극심한 고통을 받고 있는 사람이 의외로 많은 것이다.

그러나 이러한 팔꿈치 통증은 적절히 치료한다면 통증에서 벗어나 일상 생활이 충분히 가능하게 될수 있다.

      [ 팔꿈치의 기능적 해부학 ]

        팔꿈치(주관절)에는 3개의 관절이 있다.
          상완척골관절( humeroulnar joint ); 굴곡과 신전 운동
          상완요골관절( humeroradial joint) ; 회내운동, 회외운동
          요척골관절( radioulnar joint ); 회외 및 회내운동

팔꿈치 관절은 상완과 전완이 하나의 축으로 배열되어 있는데 팔꿈치 관절 부위에서는 약간 외측으로 기울린 각도(carrying angle)를 이룬다(외반).
이는 정상적으로 남자에서는 약 5 ° , 여자에서는 10 ~15 ° 정도라고 한다.
만약 팔꿈치가 외측 으로 과도히 휘었을때는 (예; carrying angle 이 15 ° 이상의 외반) 외반주(cubitus valgus)라고 하며 이는 척골신경의 비정상적 스트레스를 주어 손상을 일으킬수도 있다. 만약 팔꿈치가 내측으로 휘었을때(내반주 cubitus varus :carrying angle이 감소되었을때)도 손상을 입을수 있다.

정상적으로 팔꿈치는 굴곡운동이 140~150 ° , 신전운동 0~ -10 °, 전완의 회내 (pronation)및 회외 (supination)운동은 각각 90 °이다.
팔꿈치의 근육 작용은 상완근(brachialis)이 팔꿈치의 주 굴곡근이고 이두근(biceps)은 굴곡 및 회외운동근육이다. 
원회내근(pronator teres)과 사각회내근(pronator quadratus)은 회내운동근육이다.
팔꿈치의 외상은 주로 상완척골관절(humeroulnar joint)에 받게되는데 이는 굴곡 및 신전운동에 제한이 생기게 된다.
팔꿈치의 회전운동은 정상일수도 있다. 
만약 외상후 회내및 회외운동의 장애가 있으면 요골두(radial head)의 병변을 생각할수 있다.
상완근의 외상성 근염은 팔꿈치 굴곡운동시 제한적이고 통증을 일으킨다.

[서재현 통증의학과]

Doctors first identified Tennis Elbow (or lateral epicondylitis) more than 100 years ago. Today nearly half of all tennis players will suffer from this disorder at some point. Interestingly though, tennis players actually account for less than 5 percent of all reported cases making the term for this condition something of a misnomer.

There are 2 additional strain related conditions which are often mistaken for Tennis Elbow. These being Golfer’s Elbow & Bursitis. Before we delve into the details of what Tennis Elbow actually is and options that are available for relieving & preventing the pain...let’s look at the distinguishing characteristics of each of these 3 ailments.

Symptoms Of Tennis Elbow

• Recurring pain on the outside of the upper forearm just below the bend of the elbow; occasionally, pain radiates down the arm toward the wrist.
• Pain caused by lifting or bending the arm or grasping even light objects such as a coffee cup.
• Difficulty extending the forearm fully (because of inflamed muscles, tendons and ligaments).
• Pain that typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or as long as several years.

The damage that tennis elbow incurs consists of tiny tears in a part of the tendon and in muscle coverings. After the initial injury heals, these areas often tear again, which leads to hemorrhaging and the formation of rough, granulated tissue and calcium deposits within the surrounding tissues. Collagen, a protein, leaks out from around the injured areas, causing inflammation. The resulting pressure can cut off the blood flow and pinch the radial nerve, one of the major nerves controlling muscles in the arm and hand.

Tendons, which attach muscles to bones, do not receive the same amount of oxygen and blood that muscles do, so they heal more slowly. In fact, some cases of tennis elbow can last for years, though the inflammation usually subsides in 6 to 12 weeks.

Many medical textbooks treat tennis elbow as a form of tendonitis, which is often the case, but if the muscles and bones of the elbow joint are also involved, then the condition is called epicondylitis. However, if you feel pain directly on the back of your elbow joint, rather than down the outside of your arm, you may have bursitis, which is caused when lubricating sacs in the joint become inflamed. If you see swelling, which is almost never a symptom of tennis elbow, you may want to investigate other possible conditions, such as arthritis, infection, gout or a tumor.

Relief Of Tennis Elbow

The best way to relieve tennis elbow is to stop doing anything that irritates your arm — a simple step for the weekend tennis player, but not as easy for the manual laborer, office worker, or professional athlete.

The most effective conventional and alternative treatments for tennis elbow have the same basic premise: Rest the arm until the pain disappears, then massage to relieve stress and tension in the muscles, and exercise to strengthen the area and prevent re-injury. If you must go back to whatever caused the problem in the first place, be sure to warm up your arm for at least 5 to 10 minutes with gentle stretching and movement before starting any activity. Take frequent breaks.

Conventional medicine offers an assortment of treatments for tennis elbow, from drug injections to surgery, but the pain will never go away completely unless you stop stressing the joint. Re-injury is inevitable without adequate rest.

For most mild to moderate cases of tennis elbow, aspirin or ibuprofen will help address the inflammation and the pain while you are resting the injury, and then you can follow up with exercise and massage to speed healing.

For stubborn cases of tennis elbow your doctor may advise corticosteroid injections, which dramatically reduce inflammation, but they cannot be used long-term because of potentially damaging side effects.

Another attractive option for many sufferers, especially those who prefer to not ingest medication orally, is the application of an appropriate and effective topical anti-inflammatory. CT Cream with A.C.P.was specifically designed to reduce inflammation and does so by taking advantage of well known elements Arnica, Choline, Pyridoxine and Vitamin B6. Researched, formulated and introduced recently by Dr. Ying Lee, D.O., A.O.C.F.P., AOCPM., CT Cream has proven to be extremely successful in treating inflammation related ailments such as epicondylitis, tendonitis, bursitis & Tennis Elbow.

If rest, anti-inflammatory medications, and a stretching routine fail to cure your tennis elbow, you may have to consider surgery, though this form of treatment is rare (fewer than 3 percent of patients). One procedure is for the tendon to be cut loose from the epicondyle, the rounded bump at the end of the bone, which eliminates stress on the tendon but renders the muscle useless. Another surgical technique involves removing so-called granulated tissue in the tendon and repairing tears.

Even after you feel you have overcome a case of tennis elbow, be sure to continue babying your arm. Always warm up your arm for 5 to 10 minutes before starting any activity involving your elbow. And if you develop severe pain after use anyway, pack your arm in ice for 15 to 20 minutes and call your doctor.

Prevention

To prevent tennis elbow:

• Lift objects with your palm facing your body.
• Try strengthening exercises with hand weights. With your elbow cocked and your palm down, repeatedly bend your wrist. Stop if you feel any pain.
• Stretch relevant muscles before beginning a possibly stressful activity by grasping the top part of your fingers and gently but firmly pulling them back toward your body. Keep your arm fully extended and your palm facing outward.
   

Caution!

To prevent a relapse:

• Discontinue or modify the action that is causing the strain on your elbow joint. If you must continue, be sure to warm up for 10 minutes or more before any activity involving your arm, and apply ice to it afterward. Take more frequent breaks.
• Try strapping a band around your forearm just below your elbow. If the support seems to help you lift objects such as heavy books, then continue with it. Be aware that such bands can cut off circulation and impede healing, so they are best used once tennis elbow has disappeared.

Call Your Doctor If....

• The pain persists for more than a few days; chronic inflammation of the tendons can lead to permanent disability.
• The elbow joint begins to swell; tennis elbow rarely causes swelling, so you may have another condition such as arthritis, gout, infection or even a tumor.

Options to Prevent or Treat Osteoporosis in Postmenopausal Women
Posted Mon, Sep 08, 2008, 2:30 pm PDT
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I see where the makers of Evista® (raloxifene) are offering a 30-day free trial of this drug, which lowers the risk of both osteoporosis and breast cancer in women who have gone through menopause.

This gets me thinking about the options for osteoporosis treatment in postmenopausal women. Unlike many advertisements for dietary supplements, the ads for Evista are at least accurate — even though, as expected, they do not mention any of the other possible osteoporosis treatments for this group.

Before considering drug treatments, however, I must mention two less costly strategies that can help postmenopausal women fend off osteoporosis: exercising regularly and getting at least 1,200 mg of calcium and 800 International units of vitamin D a day.

Few diets provide these amounts of calcium, and especially of vitamin D, so most women need supplements of both. Tums® is the least expensive calcium supplement, but you need to remember that each 500 mg tablet of Tums contains only 200 mg of calcium, and that, for optimum absorption of this calcium, the tablets must be taken with meals.

The 3 available drug options for the prevention and treatment of osteoporosis in postmenopausal women are

hormone replacement therapy (HRT)
SERMs (selective estrogen-receptor modulators) such as raloxifene (Evista®)
bisphosphonates
Hormone replacement therapy. My first choice in the period immediately after the menopause is HRT, which may consist of estrogen alone or estrogen plus a progestin. Estrogen not only reduces postmenopausal symptoms such as hot flashes, but also prevents the loss of bone mass, which defines osteoporosis and is responsible for this disorder's increased risk of fractures. Because taking estrogen just by itself increases the danger of uterine cancer, those women who have not had a hysterectomy (removal of the uterus) must also take a progestin.

A low dose of estrogen should be prescribed only for a short time, perhaps no longer than 5 years, to avoid possible adverse effects. Long-term use, for example, increases the risk of stroke. Estrogens also increase the risk of breast cancer, so women with a history of breast cancer should not take estrogen replacements.

Another possible side effect of HRT, with or without a progestin, is thromboembolism (blood clots in a leg vein that may break loose as an embolus that can then move to the lungs and block a blood vessel there).

The bisphosphonates, My second treatment choice would be one of the bisphosphonates, such as alendronate (Fosamax®), risendronate (Actonel®), and ibandronate (Boniva®). These drugs, which can be started and used at any time after the menopause, can be taken by mouth once or twice a week, or even once a month, to prevent bone loss and associated fractures.

They may also slow the progression of breast cancer that has spread (metastasized) to bone and may even prevent the development of bone metastases in women newly diagnosed with breast cancer. (Bone metastases occur in more than 80 percent of women with advanced breast cancer.)

Women must drink plenty of fluids at the time they swallow these pills, and they must remain standing for at least 30 minutes to avoid damage to the esophagus. Women who cannot stand for this period of time can be treated with Boniva administered intravenously every 3 months — or with another bisphosphonate, zoledronic acid (Reclast®), once a year.

The bisphosphonates have no effect on postmenopausal symptoms. Chronic bisphosphonate therapy, however, can cause a serious, although rare, complication: osteonecrosis (death) of the jawbone, often associated with pain, swelling, exposed bone, local infections, and fracture of the jaw.

The selective estrogen-receptor modulators. SERMs such as raloxifene (Evista®) are effective in preventing and treating osteoporosis, but these drugs would not be my first choice for women in the early years of the menopause. This is because, unlike estrogen, they increase hot flashes and can even cause them in premenopausal women. Through their actions on estrogen receptors, SERMs may enhance some of estrogen's effects, while reducing others; that is, they act like estrogen on some tissues but block its effect on other tissues.

Unlike estrogen, raloxifene has an important benefit in women with breast cancer — it may reduce the risk of invasive breast cancer. Like estrogen, raloxifene raises the danger of thromboembolism, so women who have had prior blood clots in their legs should not take raloxifene. In addition, some evidence suggests that raloxifene increases the risk of dying from a stroke in those women who are at high risk for heart disease or stroke.

Postmenopausal women are fortunate that several forms of treatment can prevent osteoporosis. Each woman should decide with her gynecologist which one is best for her.

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